Neurosurgery

Neurosurgery - Guideline for antimicrobial prophylaxis

Publication: 01/04/2010

Next review: 04/12/2023

Clinical Guideline

CURRENT

ID: 1676

Approved By: Improving Antimicrobial Prescribing Group

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for antimicrobial prophylaxis in neurosurgery

Summary table of routine recommendations
Background information
Special antimicrobial prophylaxis recommendations

1. Summary table of routine recommendations

It is the responsibility of the surgical team to prescribe the prophylactic antibiotics, and the anaesthetist to ensure that they have been given within one hour before incision.

Procedure	Prophylaxis recommended?	Evidence level	Prophylaxis intended to reduce	NNT	Antimicrobial dose/route <1 hours prior to procedure.
Procedure	Prophylaxis recommended?	Evidence level	Prophylaxis intended to reduce	NNT	Routine	*MRSA risk or true penicillin allergy**
Craniotomy	YES	A (1) (2)	Wound infection	17	Flucloxacillin 1g iv single dose	Teicoplanin 400mg iv single dose
CSF shunt insertion	YES	A (1) (4)	Wound and shunt infection	16	Flucloxacillin 1g iv single dose plus Gentamicin 2mg/kg iv single dose (use IBW, see table below)	Teicoplanin 400mg iv single dose plus Gentamicin 2mg/kg iv single dose (use IBW, see table below)
Trans-sphenoidal Pituitary resection	YES	A (1) (2)	Post-operative wound infection and meningitis		Co-amoxiclav 1.2g single dose	Teicoplanin 400mg iv single dose plus Gentamicin 2mg/kg iv single dose (use IBW, see table below) plus Metronidazole 500mg iv single dose
Penetrating intracranial injury	YES	C (3)	Any infection		Co-amoxiclav 1.2g 8-hourly 5 days	Discuss with Microbiology
Basal skull fracture, CSF leak and CSF fistula	NONE	C (3)
See separate guideline for spinal surgery (currently under development

* MRSA risk factors
Patients within these categories are considered at increased risk of MRSA infection:

Known previous infection or colonisation with MRSA at any site.
Resident of a long term care facility (nursing home, residential home or any other long term residential facility) without a negative MRSA screening result.
History of inpatient hospital stay within the previous 6 months without a negative MRSA screening result

Calculate the dose

Find out the patient's sex, height, weight in kg
Read off the patient’s ideal body weight (IBW) for their sex and their height from the appropriate chart below
Compare the patient’s actual body weight (ABW) with their ideal body weight (IBW)
If the patient’s ABW is less than their IBW (i.e. they are underweight), use their ABW to estimate the gentamicin dose from the charts below
If the patient’s ABW is more than, or the same as, their IBW, use their IBW to estimate the gentamicin dose from the charts below

(To convert from imperial weight measurements to metric 1 stone = 6.35kg 1 lb = 0.45kg)

Gentamicin dosing in adult male >16years				Gentamicin dosing in adult female > 16 years
Use height to select gentamicin dose	IBW from height (kg)	Use ABW if less than IBW (kg)	Gentamicin dose (mg)	Use height to select gentamicin dose	IBW from height (kg)	Use ABW if less than IBW (kg)	Gentamicin dose (mg)
6’ 3” (1.9m) +	84.5	78 to 82	160	6’ 3” (1.9m) +	79.5	78 to 82	160
6’ 2” (1.88m)	82.2			6’ 2” (1.88m)	77.2	72 to 77	150
6’ 1” (1.85m)	79.9			6’ 1” (1.85m)	74.9
6’ (1.82m)	77.6	72 to 77	150	6’ (1.82m)	72.6
5’ 11” (1.8m)	75.3			5’ 11” (1.8m)	70.3	66 to 71	140
5’ 10” (1.78m)	73			5’ 10” (1.78m)	68	66 to 71	140
5’ 9” (1.75m)	70.7	66 to 71	140	5’ 9” (1.75m)	65.7	60 to 65	130
5’ 8” (1.72m)	68.4			5’ 8” (1.72m)	63.4
5’ 7” (1.7m)	66.1			5’ 7” (1.7m)	61.1
5’ 6” (1.67m)	63.8	60 to 65	130	5’ 6” (1.67m)	58.8	55 to 59	120
5’ 5” (1.65m)	61.5	60 to 65	130	5’ 5” (1.65m)	56.5
5’ 4” (1.62m)	59.2	55 to 59	120	5’ 4” (1.62m)	54.2
5’ 3” (1.6m)	56.9			5’ 3” (1.6m)	51.9	49 to 54	100
5’ 2” (1.57m)	54.6			5’ 2” (1.57m)	49.6	49 to 54	100
5’ 1” (1.55m)	52.3	49 to 54	100	5’ 1” (1.55m)	47.3	43 to 48	90
5’ (1.52m) or under	50	49 to 54	100	5’ (1.52m) or under	45	43 to 48	90

2. Background information

The aim of antimicrobial prophylaxis in neurosurgery is a reduction in surgical site infection. For the most common neurosurgical procedures there is evidence that antimicrobial prophylaxis is of benefit to patients and its use is recommended (1, 2). In the current era of increasing Clostridium difficile infection, Meticillin-resistant Staphylococcus aureus (MRSA) infection and increasing concerns about community-acquired MRSA, reducing the risk of acquisition of these pathogens is a major concern. It is therefore appropriate to limit the use of prophylactic antimicrobials to a single pre-operative dose in most situations.

These guidelines should be applicable to the majority of patients. Where the recommendations in these guidelines do not seem appropriate for a particular patient, the surgeon is advised to discuss the case with a microbiologist.

3. Special antimicrobial prophylaxis recommendations

Craniotomy
Antibiotic prophylaxis significantly reduces the risk of surgical site infection or sepsis in
non-shunt, clean cranial surgeries. Since Staphylococci and Streptococci remain the main causes of wound infection against which prophylaxis is aimed, Flucloxacillin is recommended, with Teicoplanin as an alternative in penicillin allergic patients and those at high risk of MRSA infection. Teicoplanin has the advantage of bolus administration, compared to the prolonged intravenous infusion of Vancomycin that is likely to hinder compliance.

CSF shunt insertion
Intraventricular prophylactic antibiotics have been shown to be associated with a significant reduction in the incidence of shunt infections (4). As antimicrobial impregnated shunts are the current practice at LTHT, a single dose of Flucloxacillin and Gentamicin has been recommended to prevent external infections. Polyvalent Pneumococcal Polysaccharide vaccine has been recommended for all patients with intra-cranial shunts.

Penetrating intracranial injury
Include penetrating missile wounds to the head, both sustained by a civilian or in a military or paramilitary context, accidental or incidental gunshot wounds, penetration by sharp instruments such as knives, screwdrivers, pencils and other wooden objects and other accidental injuries sustained from arrows, darts and pool cues during recreational activities
Level C evidence (3).

Trans-sphenoidal Pituitary surgery
The trans-sphenoidal surgical approach has been the preferred surgical procedure for most
surgical lesions. It has been classified as a clean contaminated procedure since the air filled sphenoidal sinus is crossed, therefore prophylaxis has been recommended.
Postopertaive CSF rhinorrhoea and meningitis have been described as complications with incidence ranging from 0.4 to 9% in various studies (5).

Provenance

Record:	1676
Objective:	Reduction in surgical site infection
Clinical condition:	Prophylaxis in neurosurgery
Target patient group:
Target professional group(s):	Pharmacists Secondary Care Doctors
Adapted from:

Evidence base

SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh; 2008.
Leaper D, Collier M, Evans D, Farrington M, Gibbs E, Gould K, et al. Surgical site infection: prevention and treatment of surgical site infection. In: health NCcfwac, editor.: Royal College of Obstetrics and Gynaecology, Press; 2008.
Bayston R, de Louvois J, Brown EM, Johnston RA, Lees P, Pople IK. Use of antibiotics in penetrating craniocerebral injuries. "Infection in Neurosurgery" Working Party of British Society for Antimicrobial Chemotherapy. Lancet. 2000 May 20;355(9217):1813-7.
Ragel BT, Browd SR, Schmidt RH. Surgical site infection: significant reduction when using intraventricular and systemic antibiotics. Journal of Neurosurgery 2006;105 (2):242-7
Cappabianca P, Cavallo LM, Colao A, De Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 2002; 97(2):293-8

Evidence levels
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT Consensus [no national guidelines exist, guidelines from different learned bodies contradict each other, or no evidence exists]

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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